Provider Demographics
NPI:1679303135
Name:SHAW, LYNETTE A
Entity type:Individual
Prefix:
First Name:LYNETTE
Middle Name:A
Last Name:SHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 HIGHLAND AVE NE APT 1007
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-1393
Mailing Address - Country:US
Mailing Address - Phone:309-669-7894
Mailing Address - Fax:
Practice Address - Street 1:1125 PENNY LN
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-3924
Practice Address - Country:US
Practice Address - Phone:833-432-5285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-07
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health